Illinois Department of Agriculture • Bureau of Warehouses
P.O. Box 19281 • Springfield, IL 62794-9281 • 217/782-2895 • TDD 217/524-6858 • Fax 217/524-7801
ANNUAL REPORT
AGRICULTURAL CO-OPERATIVE ACT
805 ILCS 315/
To remain in compliance with 805 ILCS 315/21 and to retain their authority to do business within the State of Illinois each
association formed under this Act shall prepare an annual report on forms to be furnished by the Director of Agriculture.
Filing is due six months after fiscal year-end.
Principal Place of Business (the principal mailing address where annual report is to be sent):
Legal Name of Company
DBA (Additional name legally authorized to do business as)
Additional Address (Building name, suite number, mail stop, etc.)
E 911 Address (physical street location – required item)
U. S. Postal Address (P. O. Box, etc.)
City
State
County
Zip Code
Company’s Telephone Number
Fax Number
Contact Person
Contact’s Telephone Number and Extension
Contact’s E-mail Address
Company’s Internet Site
Principal Illinois Location (if the same as the principal place of business just enter “SAME”):
Additional Address (Building name, suite number, mail stop, etc.)
E 911 Address (physical street location – required item)
U. S. Postal Address (P. O. Box, etc.)
City
State
County
Zip Code
Contact Person for this location:
Contact’s Telephone Number and Extension
Contact’s E-mail Address
Contact’s Fax Number
Illinois Incorporation File Number (This number was given by the Secretary of State’s office when this company originally
filed their articles of incorporation or obtained their certificate or authority) ___________________
Note: The articles of incorporation may be altered or amended at any regular meeting, or any special meeting called for that purpose. Amendments to the
articles of incorporation when so adopted shall be filed in the office of the Secretary of State. A copy shall also be sent to the Department of Agriculture.
http://www.agr.state.il.us/warehouses/whsgdinsp.html
SECTION A:
General Statement of Business Operations
1. Principal commodities, or products, handled by the cooperative: _______________________________________
____________________________________________________________________________________________
2. The cooperative has offices in the following states: __________________________________________________
____________________________________________________________________________________________
Stock Association
Non-Stock Association
Number of Stockholders:
Number of Members:
Capital Stock Paid Up:
Membership Fees:
SECTION B:
Officers and Directors (attach a separate sheet if additional space is needed)
Name:
Telephone # and Extension
President
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
Name:
Vice-President / Secretary /
Treasurer / Director (Circle One)
County:
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
Name:
County:
Vice-President / Secretary /
Treasurer / Director (Circle One)
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
Name:
County:
Vice-President / Secretary /
Treasurer / Director (Circle One)
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
Name:
County:
Vice-President / Secretary /
Treasurer / Director (Circle One)
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
Name:
County:
Vice-President / Secretary /
Treasurer / Director (Circle One)
E 911 Address (physical street location):
U. S. Postal Address (P. O. Box, etc.):
City:
State:
County:
Zip Code:
Telephone # and Extension
Zip Code:
Telephone # and Extension
Zip Code:
Telephone # and Extension
Zip Code:
Telephone # and Extension
Zip Code:
Telephone # and Extension
Zip Code:
SECTION B: Financial Information (Co-op may submit the financial statements completed by their
accountant instead of completing this section)
Fiscal Year-End _____________
CURRENT ASSETS
Cash and Cash Equivalent:
$
Receivables:
Trade Receivables:
$
Grain Receivables:
$
Notes and Other Receivables:
$
Less Allowances for Doubtful Accounts
$
Net Receivables:
$
Grain Inventory (unencumbered):
$
Grain Inventory-Collateralizing Loans:
$
Merchandise Inventory:
$
Total Inventory:
$
All Other Current Assets
$
Total Current Assets
Long-Term Assets
Investments
$
Buildings and Equipment
Less Accumulated Depreciation
Land
$
$
$
Net Property, Plant and Equipment
Other Long-Term Assets
Total Long-Term Assets
Total Assets
$
$
$
$
CURRENT LIABILITIES
Grain Received, No Price Established:
$
Other Grain Payables:
$
Trade Payable:
$
Current Debt Payables:
$
Patronage Dividends Payable:
$
Patronage Refunds Payable:
$
All Other Current Liabilities:
$
Total Current Liabilities
$
LONG-TERM LIABILITIES
Debt Payable:
$
Deferred Income Taxes:
$
Other Long-Term Liabilities:
$
Total Long-Term Liabilities
TOTAL LIABILITIES
$
$
Stockholders’ or Members’ Equity
Membership Fees:
$
Preferred Stock:
$
Common Stock:
$
Allocated Stock Credits:
$
Retained Income:
$
Paid In and Other Surplus:
$
TOTAL STOCKHOLDERS’ OR MEMBERS’ EQUITY
$
TOTAL LIABILITIES AND EQUITY
$
STATEMENT OF INCOME
Grain Sales:
$
Cost of Grain Sales:
$
Gross Grain Income:
$
Merchandise Sales
$
Cost of Merchandise Sales:
$
Gross Merchandise Income:
$
Gross Income from Sales:
$
Other Operating Income:
$
Total Gross Income:
$
Operating Expenses:
$
Net Operating Income:
$
Other Income:
$
Interest Expenses:
$
Other Expenses:
$
Patronage Refunds:
$
Dividends:
$
Total Other Income and Expenses
Income Before Taxes
$
$
Taxes:
$
NET INCOME
$
SECTION C: Fees For Filing Annual Report
$10.00
SECTION D: Signature Section
An officer of the association must sign this annual report.
__________________________________________________________________________________
NAME OF COMPANY
_________________________________
SIGNATURE
_____________________
TITLE
___________
DATE
THE FOLLOWING DOES NOT APPLY TO BUSINESSES WITH FEDERAL EMPLOYER IDENTIFICATION NUMBERS.
Pursuant to 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's Social Security
Number, and the applicant shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support
order. Failure to certify shall result in disciplinary action, and making a false statement may subject the applicant to contempt of court.
Are you more than 30 days delinquent in complying with a child support order?
Yes
No
(NOTE: If you are not subject to a child support order, answer "no.")
Applicant's Social Security Number is __________________________.
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and
to the best of my knowledge, they are true, correct, and complete.
___________________________________________
Signature of Applicant
____________________________
Date
NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois
Compiled Statues, Ch 805 par 315. Failure to provide this information shall prevent this form from being processed. IL 406-1116(04-05)